Outpatient Drug-free Programs Research Articles

Organizational correlates of service availability in outpatient substance abuse treatment programs.

In pursuit of quality care for drug abuse treatment programs, researchers continue to monitor program characteristics related to service provision. The current study examines 115 outpatient drug-free programs in four U.S. regions and documents typical methods of offering an array of services and the relationship between program characteristics and services offered onsite and by referral. Core services (e.g., comprehensive assessments) are offered primarily onsite, whereas delivery methods of wraparound services are mixed with transitional services offered generally onsite and medical services traditionally offered offsite. Accredited programs offered more core services onsite, while those providing case management offered more core and wraparound services onsite. Programs with a higher proportion of dually diagnosed clients offered more core services onsite and fewer wraparound services by referral. Programs with a higher concentration of criminal justice-referred clients offered fewer core services onsite. These findings suggest ways of improving access to services.

Relationship between drug treatment services, retention, and outcomes.

This longitudinal study conducted path analyses to examine the relationships between treatment processes and outcomes among patients in community-based drug treatment programs. A total of 1,939 patients from 36 outpatient drug-free and residential treatment programs in 13 California counties were assessed at intake, discharge, three months after admission, and nine months after admission. Path analyses were conducted to relate the quantity and quality of services that were received in the first three months of treatment to treatment retention and outcomes at the nine-month follow-up. Patients were determined to have a favorable outcome if for at least 30 days before the follow-up assessment they did not use drugs, were not involved in criminal activity, and lived in the community. The path analyses controlled for patients' baseline characteristics. Greater service intensity and satisfaction were positively related to either treatment completion or longer treatment retention, which in turn was related to favorable treatment outcomes. Patients with greater problem severity received more services and were more likely to be satisfied with treatment. These patterns were similar for patients regardless of whether they were treated in outpatient drug-free programs or residential programs. The positive association between process measures-that is, greater levels of service intensity, satisfaction, and either treatment completion or retention-and treatment outcome strongly suggests that improvements in these key elements of the treatment process will improve treatment outcomes.

Patient and program factors in obtaining supportive services in DATOS

This study examined patient and program factors that influenced the receipt of scheduled supportive services in the Drug Abuse Treatment Outcome Studies (DATOS). Patients ( N = 2,932) in 21 long-term residential (LTR) programs, 27 outpatient methadone treatment (OMT), and 25 outpatient drug-free programs were interviewed at admission and at 3 months during treatment. A hierarchical regression analysis was used to examine the relationship between patient-level and program-level factors associated with receiving supportive services in seven categories (medical, psychological, family, legal, educational, vocational, and financial). LTR patients received more services on average than outpatients (especially OMT), but patients overall received few services in the first 3 months of treatment. The patient-level likelihood of receiving services was related to being female and to having higher problem severity at intake. At the program level, outpatient clientele with higher problem severity received more services if they entered a program whose other enrolled patients were less troubled on average.

The effect of treatment completion and length of stay on employment and crime in outpatient drug-free treatment

Length of stay in treatment has been found to be a significant predictor of positive post-treatment outcomes, such as decreases in unemployment and crime. However, length of stay may be an incomplete predictor of successful treatment. Surprisingly, few studies have examined whether completing treatment in addition to length of stay is an important factor in explaining positive treatment outcomes. The objective of our study is to examine the effect that treatment completion and length of stay have on post-treatment employment and crime for patients in outpatient drug-free treatment, the largest treatment modality in the United States. We use conditional logit and multiple regression models with program-level indicator variables (fixed effects) to estimate the effect of treatment completion and length of stay on employment and crime controlling for drug use severity, previous treatment history, and other patient demographics. Data are from the National Treatment Improvement Evaluation Study and include 986 adults enrolled in outpatient drug-free programs across the United States. We find that treatment completion and length of stay are significantly related to post-treatment employment. Holding length of stay constant, the occurrence of employment at follow-up among patients who complete their planned treatment is almost 2 times that of patients who do not complete treatment. However, treatment completion did not have a statistically significant effect on the probability of post-treatment crime. Although our results are mixed, these findings suggest that greater attention should be placed on evaluating the importance of both length of stay and treatment completion in treatment outcome studies.

The economic cost of outpatient marijuana treatment for adolescents: findings from a multi‐site field experiment

Despite recent advances in the economic evaluation of adult substance abuse treatment, information and basic research is lacking on the cost of adolescent substance abuse treatment. The present study conducted an economic cost analysis of several outpatient adolescent treatment approaches. The Cannabis Youth Treatment (CYT) study evaluated five structured treatments for cannabis-using adolescents. One of the approaches was implemented by all of the four geographically and institutionally diverse treatment facilities collaborating in CYT; each of the other four approaches was implemented in two of the sites. Using the Drug Abuse Treatment Cost Analysis Program (DATCAP), the economic cost of each site-specific treatment was determined. The average economic costs of the five types of outpatient treatments ranged from $837 to $3334 per episode, and varied by both direct factors (e.g. hours of treatment, treatment retention) and indirect factors (e.g. cost of living, staff level, case-load variation). These adolescent treatment cost estimates are examined in terms of their calculation, variability by condition, variability by site within condition and comparability with previous DATCAP results from outpatient drug-free programs for adults. Future research will integrate treatment outcomes and costs to complete cost-effectiveness and benefit-cost analyses of the five therapies.

Benefit-cost analysis of addiction treatment: methodological guidelines and empirical application using the DATCAP and ASI.

To provide detailed methodological guidelines for using the Drug Abuse Treatment Cost Analysis Program (DATCAP) and Addiction Severity Index (ASI) in a benefit-cost analysis of addiction treatment. A representative benefit-cost analysis of three outpatient programs was conducted to demonstrate the feasibility and value of the methodological guidelines. Procedures are outlined for using resource use and cost data collected with the DATCAP. Techniques are described for converting outcome measures from the ASI to economic (dollar) benefits of treatment. Finally, principles are advanced for conducting a benefit-cost analysis and a sensitivity analysis of the estimates. The DATCAP was administered at three outpatient drug-free programs in Philadelphia, PA, for 2 consecutive fiscal years (1996 and 1997). The ASI was administered to a sample of 178 treatment clients at treatment entry and at 7-months postadmission. The DATCAP and ASI appear to have significant potential for contributing to an economic evaluation of addiction treatment. The benefit-cost analysis and subsequent sensitivity analysis all showed that total economic benefit was greater than total economic cost at the three outpatient programs, but this representative application is meant to stimulate future economic research rather than justifying treatment per se. This study used previously validated, research-proven instruments and methods to perform a practical benefit-cost analysis of real-world treatment programs. The study demonstrates one way to combine economic and clinical data and offers a methodological foundation for future economic evaluations of addiction treatment.

Effects of program and patient characteristics on retention of drug treatment patients

Objective: To examine effects of program and patient characteristics on patient retention in residential drug treatment programs, outpatient drug-free programs (ODF), and methadone maintenance (MM) programs. Data sources/study setting: Patient data were based on admission and discharge records for individuals entering treatment programs in Los Angeles County during 1992 and 1993. Program data were collected from program directors via a mail survey. The study sample included 26,047 patients in 87 programs. The dependent variable was patient completion of a critical threshold of treatment (360 days for MM and 180 days for the other two modalities). We applied logistic regression hierarchical linear modeling analysis for each modality. Principal findings: Threshold retention rates were generally low in all three modalities (18.1% for residential programs, 22.9% for ODF, and 13.6% for MM). An articulated programmatic focus and low caseload increased patient retention in residential programs. A lower level of group therapy focus increased patient retention in ODF programs. A low programmatic focus and a low percentage of recovering staff were associated with high retention rates among MM patients. For ODF programs, none of the slopes showed random effects, while for residential and MM programs, some program factors contributed to the explanation of the random effects in several slopes (e.g., drug use severity). Conclusion: Program practice and service provision played important roles in determining patient retention in treatment. Service providers and planners should consider these key factors to improve retention of patients, which is likely to increase overall treatment effectiveness and efficiency.

Transportation and retention in outpatient drug abuse treatment programs.

To determine whether certain types of transportation assistance improve outpatient treatment retention beyond thresholds shown to have therapeutic benefits, we analyzed data from 1,144 clients in 22 outpatient methadone maintenance (OMM) programs and 2,031 clients in 22 outpatient drug-free (ODF) programs in the Drug Abuse Treatment Outcomes Study (DATOS), a national, 12-month, longitudinal study of drug abuse treatment programs. Directors' surveys provided information about provision of car, van, or contracted transportation services or individual vouchers/payment for public transportation. Chart-abstracted treatment retention was dichotomized at 365 days for OMM and 90 days for ODF. Separate multivariate hierarchical linear models revealed that provision of car, van, or contracted transportation services improved treatment retention beyond these thresholds for both OMM and ODF, but individual vouchers or payment for public transportation did not. Future research should validate whether car, van, or contracted transportation services improve retention and other treatment outcomes in outpatient drug abuse treatment.

Dollars and performance: treating alcohol misuse in Maine

If public funds are allocated efficiently, then an increase in funding should improve the performance of substance abuse treatment programs. In the data used in this paper, performance (measured as abstinence rates) and expenditures per patient are not positively correlated. One explanation is that funding is endogeneous, i.e. programs treating more difficult patients receive more funding. The data comes from all Maine’s outpatient drug-free programs that received public funding between 1991 and 1994. After controlling for endogeneity, this paper concludes that the marginal impact of expenditures per patient on abstinence rates is small and statistically insignificantly different from zero.

Prior treatment experience related to process and outcomes in DATOS

Using data collected from cocaine-abusing patients who participated in the Drug Abuse Treatment Outcome Studies (DATOS), we contrasted patients in treatment for the first time and patients having extensive histories of prior treatment to identify factors associated with better outcomes in each group. Compared with first-timers, treatment-experienced patients had less favorable post-treatment outcomes. Indicators of early engagement in DATOS treatment predicted post-treatment abstinence for both groups. Importantly, the interaction of treatment history and several process measures affected post-treatment abstinence. For example, individual counseling and program compliance had greater impacts on abstinence among treatment repeaters in outpatient drug-free programs than for first-timers. Social support and environmental context were significantly related to abstinence. These findings confirm the importance of considering treatment process and aftercare in developing and implementing strategies to optimize treatment for patients with different treatment histories.

Costs and benefits of treatment for cocaine addiction in DATOS

Our objective was to examine the cost of long-term residential (LTR) and outpatient drug-free (ODF) treatments for cocaine-dependent patients participating in the Drug Abuse Treatment Outcome Studies (DATOS), calculate the tangible cost of crime to society, and determine treatment benefits. Subjects were 502 cocaine-dependent patients selected from a national and naturalistic nonexperimental evaluation of community-based treatment. Financial data were available for programs from 10 US cities where the subjects received treatment between 1991 and 1993. Treatment costs were estimated from the 1992 National Drug Abuse Treatment Unit Survey (NDATUS), and tangible costs of crime were estimated from reports of illegal acts committed before, during, and after treatment. Sensitivity analyses examined results for three methods of estimating the costs of crime and cost-benefit ratios. Results showed that cocaine-dependent patients treated in both LTR and ODF programs had reductions in costs of crime from before to after treatment. LTR patients had the highest levels and costs of crime before treatment, had the greatest amount of crime cost reductions in the year after treatment, and yielded the greatest net benefits. Cost-benefit ratios for both treatment modalities provided evidence of significant returns on treatment investments for cocaine addiction.

Patient histories, retention, and outcome models for younger and older adults in DATOS

Structural equation modeling with multiple groups was used to examine relationships among pretreatment patient characteristics, treatment retention, and treatment outcomes among younger and older adults in the Drug Abuse Treatment Outcome Studies. Separate models were tested for 551 patients treated in long-term residential (LTR) programs and 571 patients treated in outpatient drug-free (ODF) programs. There was a stronger positive relationship between treatment retention and abstinence at follow-up for younger adults in both treatment modalities. Prior treatment history had a negative effect on self-efficacy to resist drug use for older adults in LTR. Negative reference group influence was reduced for all groups following treatment, however, it was more strongly related to abstinence for younger adults in LTR and for older adults in ODF. Clinical implications of age-related differences in these relationships are discussed.

Treatment for drug dependence.

Drug abuse treatment is a major method for reducing the health and social problems associated with dependence on psychoactive drugs. Drug dependence is very well established in the United States, where cyclical rises and falls in the use of different drugs often occur. Heroin and cocaine use are spreading rapidly throughout the world as a whole, particularly in developing countries. The need for effective treatments for drug dependence is likely to increase in the foreseeable future. Currently three major forms of long-term drug abuse treatment exist: methadone maintenance, in which an agonist medication is used to normalize physiological functioning; residential therapeutic communities, which are based on "resocializing" the drug user; and outpatient drug-free programs, which utilize a wide variety of counseling and psychotherapy approaches. Multiple large treatment outcome studies have been conducted among persons receiving treatment for drug dependence and have shown consistent effects in reducing the use of psychoactive drugs, though complete elimination of drug use is an infrequent outcome. Length of time in drug treatment is the best single predictor of positive post-treatment outcomes. HIV infection has become an extremely important adverse consequence associated with the injection of psychoactive drugs. Multiple studies have shown that drug abuse treatment is an effective method for preventing HIV infection among injecting drug users.

Effects of readiness for drug abuse treatment on client retention and assessment of process.

This study examined client motivation as a predictor of retention and therapeutic engagement across the major types of treatment settings represented in the third national drug abuse treatment outcome study (DATOS) conducted in the United States. Sequential admissions during 1991-93 to 37 programs provided representative samples of community-based treatment populations. Based on this naturalistic non-experimental evaluation design, hierarchical linear model (HLM) analysis for nested data was used to control for systematic variations in retention rates and client attributes among programs within modalities. The data were collected from long-term residential (LTR), outpatient methadone (OMT) and outpatient drug-free (ODF) programs located in 11 large cities. A total of 2265 clients in 18 LTR, 981 clients in 13 OMT and 1791 clients in 16 ODF programs were studied. Pre-treatment variables included problem recognition and treatment readiness (two stages of motivation), socio-demographic indicators, drug use history and dependence, criminality, co-morbid psychiatric diagnosis and previous treatment. Retention and engagement (based on ratings of client and counselor relationships) served as outcome criteria. Pre-treatment motivation was related to retention in all three modalities, and the treatment readiness scale was the strongest predictor in LTR and OMT. Higher treatment readiness also was significantly related to early therapeutic engagement in each modality. Indicators of intrinsic motivation--especially readiness for treatment--were not only significant predictors of engagement and retention, but were more important than socio-demographic, drug use and other background variables. Improved assessments and planning of interventions that focus on stages of readiness for change and recovery should help improve treatment systems.

Relationships Between Drug Treatment Careers and Outcomes

A structural equation modeling approach was used to examine the relationships among charac teristics of drug use and treatment careers, length of stay in a current treatment episode, and subsequent drug use among 2,807 clients participating in the Drug Abuse Treatment Outcome Study (DATOS). The model was tested separately for four major modalities. Length of stay in DATOS treatment was significantly related to reduced cocaine use (but not heroin use) during the follow-up period among clients in outpatient drug-free and residential programs and to reduced heroin use (but not cocaine use) among clients in methadone maintenance. Importantly, longer treatment careers were significantly associated with increased length of stay in DATOS outpatient drug-free programs and were associated with reduced heroin use among clients treated in all modalities except for residential programs, demonstrating cumulative treatment effects. These findings support the notion that treatment effects may accumulate across multiple treatment episodes.

Effects of readiness for drug abuse treatment on client retention and assessment of process

Aims. This study examined client motivation as a predictor of retention and therapeutic engagement across the major types of treatment settings represented in the third national drug abuse treatment outcome study (DATOS) conducted in the United States. Design. Sequential admissions during 1991‐93 to 37 programs provided representative samples of community‐based treatment populations. Based on this naturalistic non‐experimental evaluation design, hierarchical linear model (HLM) analysis for nested data was used to control for systematic variations in retention rates and client attributes among programs within modalities. Setting. The data were collected from long‐term residential (LTR), outpatient methadone (OMT) and outpatient drug‐free (ODF) programs located in 11 large cities. Participants. A total of 2265 clients in 18 LTR, 981 clients in 13 OMT and 1791 clients in 16 ODF programs were studied. Measurements. Pre‐treatment variables included problem recognition and treatment readiness (two stages of motivation), socio‐demographic indicators, drug use history and dependence, criminality, co‐morbid psychiatric diagnosis and previous treatment. Retention and engagement (based on ratings of client and counselor relationships) served as outcome criteria. Findings. Pre‐treatment motivation was related to retention in all three modalities, and the treatment readiness scale was the strongest predictor in LTR and OMT. Higher treatment readiness also was significantly related to early therapeutic engagement in each modality. Conclusions. Indicators of intrinsic motivation‐especially readiness for treatment‐were not only significant predictors of engagement and retention, but were more important than socio‐demographic, drug use and other background variables. Improved assessments and planning of interventions that focus on stages of readiness for change and recovery should help improve treatment systems.

Dollars and Performance: Cost Effectiveness of Substance Abuse Treatment in Maine

If public funds are allocated efficiently, then an increase in expenditures should improve the performance of substance abuse treatment programs. However, the unconditional correlation between performance and expenditures per patient is non-positive in the data sets used in this paper. One explanation for this seemingly surprising result is that programs that treat more difficult patients receive more resources per patient. This paper addresses this potential endogenity both theoretically and empirically. It asks whether the fraction of patients that are abstinent 30 days prior to their discharge is affected by resources. We use data from outpatient drug-free programs that received public funding from the state of Maine between 1991 and 1994. A formal model of the allocation of public funds across treatment programs shows that the endogeneity of funds can lead to underestimation of their marginal impact on performance. The model produces a system of structural equations with cross-equation restrictions. Maximum likelihood estimation of this system gives parameter estimates that strongly reject the restrictions. The model may fail either because it is incorrect or because their are omitted variables correlated with expenditures per patients. Both problems are avoided by estimating only a single equation and using instrumental variables to control for omitted variables. This approach has the additional advantage of controlling for fixed effects without introducing estimation bias. Both the structural and instrumental variable estimates indicate that the marginal impact of spending per patient on performance is very small and, in general, not statistically different from zero.

Interaction Effects of Client and Treatment Program Characteristics on Retention: An Exploratory Analysis Using Hierarchical Linear Models

This paper applied a hierarchical linear modeling approach to explore the interaction effects of treatment program and client characteristics on client retention in treatment for drug users. Program characteristics included services provision, funding sources, and staff-client gender congruence, and client characteristics included gender, age at admission, and drug use level prior to admission. The same model was applied separately to three modalities: residential, methadone maintenance, and outpatient drug-free programs. Data were obtained from 59 treatment programs and 3,764 of their clients who had discharge records. The most noteworthy significant interaction effect detected was program's funding source and client's gender on treatment retention in the outpatient drug-free modality. for example, female clients remained less time in the programs that accepted only public funding than in the programs that accepted both public and private funding. Male clients remained in the treatment an average of 25.3 fewer days than female clients in drug-free programs that only accepted public fund, but stayed about the same time as females if the programs received mixed funding.

A county survey of mental health services in drug treatment programs.

Forty-five administrators of drug treatment programs in Los Angeles County were surveyed about the adequacy of mental health services within their program and the drug treatment system. Approximately half agreed that dually diagnosed clients are not served within the system, and the majority noted that their programs restrict admission of such clients. Administrators of outpatient drug-free programs and methadone maintenance programs were more likely to characterize their mental health services as inadequate or unavailable than were administrators of other types of programs. The findings suggest the need to increase awareness of the treatment needs of dually diagnosed clients in drug treatment programs.

Family and client characteristics as predictors of outpatient treatment outcome for adolescent drug abusers.

Adolescent drug abuse clients (N = 176) and their mothers, in six different outpatient drug-free programs, were assessed at admission and at follow-up, 15 months after initiation of treatment. Family therapy sessions were offered in all six programs programs in addition to individual and group counseling. The pretreatment assessment procedures, and thus also the variables analyzed for prediction of treatment outcome, emphasized family measures (including the Family Environment Scale, the Family Adaptability and Cohesion Scale, the Parent-Adolescent Communication Inventory, and other information about the family and the parents). Multiple regression analysis determined which of three demographic variables and 39 other independent pretreatment predictor variables had a significant relationship with each of the six outcome criteria (dependent variables). Four of these outcome criteria were based on client information, and two were based on information provided by the mother. The more positively the family's functioning and relationships were described by the client at pretreatment, the more client improvement was reported by either client or mother at follow-up. Eleven of the 12 predictor variables that were found to be significantly related to any of the treatment outcome criteria were measures, at pretreatment, either of the client's perceptions of family functioning, or of his or her relationship with parents, particularly with the mother. These findings show the power of the family factors as indicators of prognosis. The predictor variable that was found to have the largest number of significant relationships, predicting three of the six outcome criteria, was the "family independence" dimension of the FES (i.e., "The extent to which family members are encouraged to be assertive, self-sufficient"). It appears that the FES instrument may be quite effective for predicting improvements in the behavior of adolescent drug-abusing clients.